Job summary
North Kerrier
East Primary Care Network (PCN)
Part-time Care Coordinator - upto 25 hours per week - Fixed Term for 6 months
Would you like to be part of
an inclusive, supportive, and innovative team, that is co-located and where it
is essential to enjoy daily coffee with your colleagues? good beans provided! If you think
you would be interested in joining our Health and wellbeing team then read
on.
The Care
Coordinator is an integral part of the PCN Health and Well-being team and is a
key contact to support people navigate and signpost to other key services.
Main duties of the job
The Care
Coordinator will be involved in supporting clinical teams to proactively
identify and work with people, including the frail/elderly and those with
long-term conditions, eg diabetes, cancer, mental health and COPD, to provide
proactive, person-centred care planning, helping coordinate care, by bringing
together the different specialists whose help that individual might need. This
might involve a wide range of services, such as hospital care, community care,
social care, housing and the voluntary sector.
The
role will support the delivery of better outcomes for people living with
multiple long-term conditions, to help them improve the quality of their life,
fostering self-care, independence and choice.
About us
Based in the West Integrated Care Area, North Kerrier East Primary Care Network, are a forward thinking group of GP
practices (Leatside Health Centre and Veor Surgery) supporting a local population of
just over 30,000, providing clinical services and health and wellbeing support to people living in the
towns of Redruth and Camborne, as well as surrounding villages. We have a
strong focus on health promotion and personalised care, supporting people to
make informed decisions about their health and social care.
Job description
Job responsibilities
- Work as part of the PCN health and wellbeing team, coordinating care
between GPs, practice nurses, clinical pharmacists, physiotherapists, mental
health practitioners, and health and well-being coaches;
- Record all patient contacts and work on the clinical system against the patient
record;
- Work with
individual patients, their families and carers, using a holistic approach, to identify
their goals for care, and agree a personalised care and support plan for their
care or support with signposting to other services;
- Support
delivery of care plans by co-coordinating input from a
range of different professionals and services, and helping patients and their
carers/family to navigate across health and social care services;
- Help
patients to manage their needs through answering queries, being a first point
of contact across the PCN, and by making and managing appointments;
-
Support patients to utilise decision aids in
preparation for a shared decision-making conversation
and ensure that they, and their carers/family, have access to good quality
written and verbal information to help them make choices about their care;
- Make use of tools such as patient health questionnaires when engaging
with patients;
- Help patients to access self-management education courses, peer support
or other interventions that support them in improving their health and wellbeing.
- Undertake regular reviews of the personalised care and support plans
developed with patients;
- Work in
line with national best practice when developing personalised care and support
plans;
- Work with patients over the phone, in person in
the practice or for those who are housebound where necessary carry out home
visits.
-
As directed, use practice level reports to identify suitable cohorts
of patients to deliver personalised care, supporting with specialist clinics;
-
Provide accurate and timely data to support audit and
monitoring of the service, and any data returns as required by the West Integrated
Care Area;
-
Keep accurate and up to date records of contacts with patients and
their carers families in clinical systems and in their care plan;
-
Follow up documentation required for care planning from other
organisations, making use of Local Care Record where useful;
-
Ensure
that a proper handover of care between different settings has taken place, including
mutual transfer of all organisations communications and patient notes and
ensuring care packages are set up;
-
Manage
any necessary meetings to support care planning, identifying patients for
discussion, organising the meeting and circulating required information
beforehand as necessary
-
Ensure
that meeting actions are recorded, disseminated and followed up in a timely
way; so relevant practitioners are aware of meeting decisions and actions /
outcomes, and chase for action resolution and update;
-
Network
and develop strong relationships with key organisations involved in the patients
care planning;
- General administration duties to support the Primary
Care Network Business Manager and team.
- Please note this is not a clinical role.
Job description
Job responsibilities
- Work as part of the PCN health and wellbeing team, coordinating care
between GPs, practice nurses, clinical pharmacists, physiotherapists, mental
health practitioners, and health and well-being coaches;
- Record all patient contacts and work on the clinical system against the patient
record;
- Work with
individual patients, their families and carers, using a holistic approach, to identify
their goals for care, and agree a personalised care and support plan for their
care or support with signposting to other services;
- Support
delivery of care plans by co-coordinating input from a
range of different professionals and services, and helping patients and their
carers/family to navigate across health and social care services;
- Help
patients to manage their needs through answering queries, being a first point
of contact across the PCN, and by making and managing appointments;
-
Support patients to utilise decision aids in
preparation for a shared decision-making conversation
and ensure that they, and their carers/family, have access to good quality
written and verbal information to help them make choices about their care;
- Make use of tools such as patient health questionnaires when engaging
with patients;
- Help patients to access self-management education courses, peer support
or other interventions that support them in improving their health and wellbeing.
- Undertake regular reviews of the personalised care and support plans
developed with patients;
- Work in
line with national best practice when developing personalised care and support
plans;
- Work with patients over the phone, in person in
the practice or for those who are housebound where necessary carry out home
visits.
-
As directed, use practice level reports to identify suitable cohorts
of patients to deliver personalised care, supporting with specialist clinics;
-
Provide accurate and timely data to support audit and
monitoring of the service, and any data returns as required by the West Integrated
Care Area;
-
Keep accurate and up to date records of contacts with patients and
their carers families in clinical systems and in their care plan;
-
Follow up documentation required for care planning from other
organisations, making use of Local Care Record where useful;
-
Ensure
that a proper handover of care between different settings has taken place, including
mutual transfer of all organisations communications and patient notes and
ensuring care packages are set up;
-
Manage
any necessary meetings to support care planning, identifying patients for
discussion, organising the meeting and circulating required information
beforehand as necessary
-
Ensure
that meeting actions are recorded, disseminated and followed up in a timely
way; so relevant practitioners are aware of meeting decisions and actions /
outcomes, and chase for action resolution and update;
-
Network
and develop strong relationships with key organisations involved in the patients
care planning;
- General administration duties to support the Primary
Care Network Business Manager and team.
- Please note this is not a clinical role.
Person Specification
Qualifications
Essential
- Good level of education.
- Proficient in the use of technology, supported with relevant qualifications and proven experience.
Desirable
- Higher level qualification such as NVQ in health and social care Level 3.
- Qualification relevant to health or social care or children.
- IT qualifications.
Experience
Essential
- Experience of working in health, social care, third sector or information and support services with direct contact with people, families, and professionals.
- Customer care experience.
- Significant proven experience in organisation, planning and coordinating skills.
- Ability to prioritise own workload, use initiative and meet deadlines.
- Able to analyse and interpret data.
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience.
- Proven experience in using computers with an ability to use Microsoft office packages and IT systems.
- Driving license and access to transport.
Desirable
- Experience of working in health services.
- Experience of working as a care coordinator or social prescriber.
- Experience or training in personalised care and support planning.
- Experience of working with elderly, children or vulnerable people, complying with best practice and relevant legislation.
Person Specification
Qualifications
Essential
- Good level of education.
- Proficient in the use of technology, supported with relevant qualifications and proven experience.
Desirable
- Higher level qualification such as NVQ in health and social care Level 3.
- Qualification relevant to health or social care or children.
- IT qualifications.
Experience
Essential
- Experience of working in health, social care, third sector or information and support services with direct contact with people, families, and professionals.
- Customer care experience.
- Significant proven experience in organisation, planning and coordinating skills.
- Ability to prioritise own workload, use initiative and meet deadlines.
- Able to analyse and interpret data.
- Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience.
- Proven experience in using computers with an ability to use Microsoft office packages and IT systems.
- Driving license and access to transport.
Desirable
- Experience of working in health services.
- Experience of working as a care coordinator or social prescriber.
- Experience or training in personalised care and support planning.
- Experience of working with elderly, children or vulnerable people, complying with best practice and relevant legislation.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details
Employer name
North Kerrier East PCN
Address
C/O Leatside Health Centre
Forth Noweth, Chapel Street
Redruth
Cornwall
TR15 1AU